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Exploration of the Association between Nurses’ Moral Distress and Secondary Traumatic Stress Syndrome: Implications for Patient Safety in Mental Health Services



Work-related moral distress (MD) and secondary traumatic stress syndrome (STSS) may be associated with compromised health status among health professionals, reduced productivity, and inadequate safety of care. We explored the association of MD with the severity of STSS symptoms, along with the mediating role of mental distress symptoms. Associations with emotional exhaustion and professional satisfaction were also assessed. This cross-sectional survey conducted in 206 mental health nurses (MHNs) was employed across public sector community and hospital settings in Cyprus. The analysis revealed that MD (measured by the modified Moral Distress Scale) was positively associated with both STSS (measured by the Secondary Traumatic Stress Scale) and mental distress symptoms (assessed by the General Health Questionnaire-28). The association of MD with STSS symptoms was partially mediated by mental distress symptoms. This association remained largely unchanged after adjusting for gender, age, education, rank, and intention to quit the job. Our findings provide preliminary evidence on the association between MD and STSS symptomatology in MHNs. Situations that may lead health professionals to be in moral distress seem to be mainly related to the work environment; thus interventions related to organizational empowerment of MHNs need to be developed.
Research Article
Exploration of the Association between Nurses’
Moral Distress and Secondary Traumatic Stress Syndrome:
Implications for Patient Safety in Mental Health Services
Maria Christodoulou-Fella,1,2 Nicos Middleton,2
Elizabeth D. E. Papathanassoglou,3and Maria N. K. Karanikola2
1Mental Health Services, Ministry of Health, Nicosia, Cyprus
2Department of Nursing, School of Health Sciences, Cyprus University of Technology, No. 15, Vragadinou str, 3041 Limassol, Cyprus
3Faculty of Nursing, 5-262 Edmonton Clinic Health Academy (ECHA), University of Alberta, 11405-87th Ave.,
Edmonton, AB, Canada T6G 1C9
Correspondence should be addressed to Maria N. K. Karanikola;
Received 1 June 2017; Revised 26 August 2017; Accepted 26 September 2017; Published 25 October 2017
Academic Editor: Giorgi Gabriele
Copyright ©  Maria Christodoulou-Fella et al. is is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Work-related moral distress (MD) and secondary traumatic stress syndrome (STSS) may be associated with compromised health
status among health professionals, reduced productivity, and inadequate safety of care. We explored the association of MD with the
severity of STSS symptoms, along with the mediating role of mental distress symptoms. Associations with emotional exhaustion
and professional satisfaction were also assessed. is cross-sectional survey conducted in  mental health nurses (MHNs) was
employed across publicsec torcommunity and hospital settings in Cyprus. e analysis revealed that MD (measured by the modied
Moral Distress Scale) was positively associated with both STSS (measured by the Secondary Traumatic Stress Scale) and mental
distress symptoms (assessed by the General Health Questionnaire-). e association of MD with STSS symptoms was partially
mediated by mental distress symptoms. is association remained largely unchanged aer adjusting forgender, age, education, rank,
and intention to quit the job. Our ndings provide preliminary evidence on the association between MD and STSS symptomatology
in MHNs. Situations that may lead health professionals to be in moral distress seem to be mainly related to the work environment;
thus interventions related to organizational empowerment of MHNs need to be developed.
1. Introduction
Healthcare organizations are not simply institutes which
provide care; they are also workplaces for over  million
workers worldwide []. People employed in healthcare ser-
vices are exposed daily to a complex variety of health and
safety hazards which include psychosocial risks, such as those
associated with work-related stress []. Nursing personnel
is the largest group of health professionals in healthcare
systems. us, nurses are oen on the epicenter of empirical
research on work-related stress, which has been associated
not only with substandard quality and safety of care [, ],
compromised safety among personnel [–].
Over a decade ago, the Word Health Organization,
recognizing work-related risks as a public health priority,
stated the need for better management of work-related risks
for healthcare workers []. Additionally, evidence shows that
the protection of mental and physiological well-being of
healthcare workers contributes to increased quality and safety
of patient care as well as to the sustainability of healthcare
e   Wo r l d H e a l t h R ep o r t “ Wo r k in g To g e t h e r f o r
Health” on human resources mentioned a global shortage
of healthcare employees, mainly nurses, which had reached
crisis levels in  countries, including the Eastern Mediter-
ranean region []. As a response, during the last decade, there
has been increased focus on ways to decrease the severity and
BioMed Research International
Volume 2017, Article ID 1908712, 19 pages
BioMed Research International
adverse impact of work-related risks on nurses and physicians
in order to improve sta retention and prevent turnover.
1.1. Literature Review. Over the last decade, a body of evi-
dence accumulated from research in occupational medicine
and organizational psychology indicates new and broader
sources of work-related stress for nurses, such as moral
distress [, ]; severe degree of professional burnout [, ,
workplace originated traumas, such as secondary traumatic
stress syndrome symptoms [–].
Although both, moral distress and secondary traumatic
stress syndrome, have been identied as occupational hazards
for health professionals providing care to vulnerable popula-
tions, that is, consumers of Mental Health Services, little is
known about the association between them [, ], as well
as their link with work-related adverse phenomena (i.e., low
job satisfaction, professional burnout, intention to resign, and
absence of empathy), especially more so in highly stressful
work environments such as Mental Health Services [, –
]. Additionally, although both syndromes have similar
manifestations, for example, physiological arousal, functional
impairment, and distressing emotions, there are scant data
in mental health nurses about the association with mental
distress, as dened by compromised mental health status
expressed by general symptoms of mental disturbance, for
example, anxiety and depressive symptoms [, , ].
In more detail, moral distress arises when one must act
in a way that contradicts his/her personal beliefs and values
[]. us, moral distress manifests as suering experienced
by health professionals when they know which is the right
moral decision; however, they are unable to implement this
coworkers or the norms and practices of the institution [].
Moral distress in nurses has been associated with psycholog-
ical discomfort and low patient safety standards, for example,
dysfunctional communication among clinicians, medication
errors, and dysfunctional work attitudes, including burnout,
intention to quit the work, and low job satisfaction [, , ].
Job satisfaction reects ones positive emotions in relation
to her/his occupation []. A central dimension of health
professionals’ job satisfaction is satisfaction from therapeutic
relationships, which reects the amount of positive feelings
experienced by clinicians in relation to the therapeutic
encounter with consumers of healthcare services [].
Secondary traumatic stress syndrome (STSS) develops in
health professionals who come into continuous and close
contact with trauma survivors, while experiencing con-
siderable emotional disruption themselves, thus becoming
indirect victims of the trauma, they care for [, ]. To
date, there has been evidence from cross-sectional studies
in nurses which associate STSS with mental and somatic
distress symptoms, low job satisfaction, and burnout [–];
On the other hand, professional burnout involves a state
of emotional, physiological, and personal esteem distress
resulting from exposure to prolonged work-related stressful
conditions []. e core concept of professional burnout
is emotional exhaustion, which regards experiences of psy-
chological fatigue related to work conditions, while in this
state ones drive is replaced by tiredness, commitment by
cynic behaviour, and eciency by low motivation [].
Experiences of emotional exhaustion in nurses have been
linked with both moral distress [] and STSS [], as well
as reduced productivity, low job satisfaction, high rates of
resignations and turnover [], low patient safety standards [,
], and mental distress, for example, anxiety and depressive
symptoms [].
Anxiety and depressive symptoms in nurses are also
associated with adverse work behaviours, such as avoidance,
as well as high percentages of mistakes during medication
administration []. Additionally, both mental and physical
distress in nurses are related to increased percentages of sick
leaves [], resignations, turnover, or even discouragement
of young people to follow this profession []. Furthermore,
not only is nurses’ mental distress related to low patient safety
standards and reduced productivity but it may also lead to
health system burden, as far as nancial and human resources
are concerned [, , ].
Additionally, nurses’ mental distress and psychological
discomfort, that is, emotional exhaustion, STSS symptoms,
low job satisfaction, and moral distress, seem to be associated
with impersonal attitude towards patients, indierence, and
anger manifestations [, , ], negatively inuencing the
quality of interaction with the consumers of health services
therapeutic relationship constitutes a fundamental element
of the quality of care provision, as well as patient safety
standards [–], while empathy is a core clinical skill
clinicians’ ability to understand the unique experiences of
others, for example, patients and their families, and com-
municate their understanding with them [–]. Despite
the importance of nurses’ empathy and satisfaction from
therapeutic relationships in clinical settings, studies related
to this issue are limited, particularly their association with
work-related stressors and manifestation of mild psychiatric
symptoms [, ].
Taking into consideration the aforementioned evidence,
the exploration and subsequent eective management of both
work-related stress and potentially mental distress in nurses
are considered highly important []. In this context, the aim
of this study was to explore the association of the intensity
and frequency of morally distressing situations with symptom
severity of secondary traumatic stress syndrome, the poten-
tially mediating eect of mental distress in this association,
and possible associations with work-related adverse attitudes,
among mental health nurses in Cyprus.
1.2. e Context of Mental Health Services. Nurses employed
in Mental Health Services (MHN) may encounter a series
of ethical issues and related problems, which may lead
to morally distressing experiences [, ]. Moral distress
is a phenomenon of increasing concern in mental health
nursing practice, education, and research due to the increased
BioMed Research International
frequency of ethically and morally charged situations in
mental healthcare settings compared to other clinical con-
texts [, , ]. e psychopathological changes in people
suering from mental illness may undermine their capacity
to consent treatment procedures []. e consequences
may range from nonparticipation in clinical decision-making
to restrictive measures for risk prevention and treatment,
such as involuntary admissions, involuntary intramuscular
medication, or physical restraint []. Informed consent for
treatment encompasses information giving, comprehension,
and volunteerism; thus these situations may be viewed as
violation of the main bioethical principles in healthcare
treatment, that is, autonomy, nonmalecence, benecence,
and justice causing ethical and subsequent psychological
discomfort to clinicians []. Additionally, neurocognitive
dysfunction in people experiencing mental illness, for exam-
ple, disturbed thought processes, hallucinations, or illusions,
may jeopardize their critical thinking capacity and render
them vulnerable to violent or deceptive behaviours, even
healthcare workers, arising morally stressful issues in MHNs
who are endorsed to advocate for patients and their families
[]. In other cases, MHNs may judge that the adminis-
tration of pharmacological restrictive measures is not the
most appropriate approach for an irritated patient; however
they may follow the expectation to implement it according
to physicians orders []. In such cases, MHNs may feel
morally burdened, even though they may not be able to
change what is happening [, , ]. Overall, morally
distressing experiences may have a traumatic eect on the
since MHNs suering from moral distress describe feelings
of frustration, anger, and guilt [], usually expressed as
general symptoms of mental distress, for example, anxiety
and depressive symptoms [].
In addition, people suering from mental illness very
oen describe themselves, aer being exposed to traumatic
experiences, as trauma survivors []. Since secondary trau-
matic stress syndrome concerns the prolonged eects of a
traumatic event to those who care for trauma survivors, one
may argue that those who care for the mentally ill may also
experience the indirect eect of these traumatic experiences
traumatic stress syndrome, emotional exhaustion has also
been identied as a job-related hazard for MHNs. Studies
in MHNs have reported association between emotional
exhaustion and several health outcomes, including low self-
reported somatic health level [, ], anxiety and depressive
symptoms [, ], or higher risk of health-threatening
behaviours, such as tobacco smoking [] or consumption of
alcohol [].
e main work-related stressors encountered by MHNs,
possibly associated with psychosocial and job-related haz-
those stressors related to the therapeutic relationship and
the nursing process of care, namely, challenging behaviours
by patients and their family members, physical and verbal
violent behaviour towards clinicians by patients, patients’
suicidal behaviour, nonadherence to therapy, and insucient
time to provide optimal care, and those related to the working
context, that is, poor stang, inadequate referral systems,
heavy workload, insucient resources, type of working
setting (community versus hospital settings), and uncertainty
of employment.
e aforementioned stressors have been associated with
emotional exhaustion, intention to quit the job, low job
satisfaction, and diminished engagement in the therapeutic
process in mental health nursing populations. e latter may
be expressed by absence of empathy [, , , , ]. At the
same time, the above stressors may trigger morally distressing
experiences in MHNs, as well [–, ]. Data, mostly from
qualitative studies, show that, due to heavy workload and
time pressure linked with insucient stang, MHNs very
oen are not able to develop a therapeutic relationship and
eective communication with patients, while in other cases
healthcare professionals may keep the restriction measures,
even if it is not necessary due to these reasons. Yet, these
ndings may support possible explanations regarding how
stressful work conditions and relevant circumstances may
be linked not only with emotional exhaustion, but also with
morally and ethically disturbing experiences.
2. Aim
e aim of the present study was to explore, among mental
health nurses in Cyprus, the following: (a) the frequency
and intensity of morally distressing (MD) situations, (b) the
severity of symptoms of secondary traumatic stress syndrome
(STSS) and mental distress, as well as the degree of emotional
exhaustion and job satisfaction, (c) the association among
MD, STSS, and mental distress symptoms, (d) the association
of MD and STSS symptoms with sociodemographic factors
and work-related features, including job satisfaction, satisfac-
tion from therapeutic relations, emotional exhaustion, and
empathy, and (e) the extent to which self-rated degree of
general mental distress symptoms mediates the association
between MD and STSS symptoms.
In order to address the aforementioned objectives, the
(i) What is the frequency and intensity of morally dis-
tressing experiences?
(ii) What is the degree of (i) symptoms of STSS, (ii) symp-
toms of mental distress, (iii) empathy, (iv) emotional
exhaustion, and (v) job satisfaction?
(iii) Is there any association between MD measures (i.e.,
intensity and frequency) and the severity of symp-
toms of (i) mental distress and (ii) STSS?
(iv) Is there any association between MD measures and
(i) sociodemographic factors and (ii) work-related
factors, that is, job satisfaction and satisfaction
from therapeutic relations, emotional exhaustion, and
(v) Does self-rated degree of general mental distress
symptoms mediate the association between MD mea-
sures and the severity of STSS symptoms?
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3. Materials and Methods
3.1. Study Design and Setting. e study was designed as a
cross-sectional descriptive correlational study with the use of
self-reported questionnaire scales. Aer the reform following
deinstitutionalization in Europe and the USA, Mental Health
Services in Cyprus are provided in a wide range of settings,
including both hospital and community-based services. e
(child and adolescent Mental Health Services, day hospitals,
and addiction treatment programs). Hospital-based services
include acute services in the psychiatric clinics of the general
hospitals and institutional services in Athalassa Psychiatric
Hospital, which is Cyprus’ main psychiatric hospital.
3.2. Ethical Issues. e study protocol was approved by
the Cypriot National Bioethics Committee (PN: CNBV/EP/
/) and the Research Promotion Committee of the
Ministry of Health (PN: ....E). Moreover, the Com-
missioner for Personal Data Protection was notied as
required (PN: ..). e questionnaire packet included
an information sheet explaining the aim of the study and
the voluntary nature of participation. Participants signed
an informed consent form. Participation was anonymous.
Names or any other personal information which could reveal
the identity of the respondents was not reported at any part
of the questionnaire. Condentiality was guaranteed and the
completed questionnaires were returned in nontransparent
sealed envelopes. Permissions were obtained for the use of all
copyrighted questionnaire scales.
3.3. Eligibility and Sample. e target population consisted
of all registered MHNs employed in the public sector either
in child/adolescent or in adult Mental Health Services, in
any of the aforestated settings (𝑁 = 360). Eligibility criteria
included employment in a clinical setting for at least six
work experience or seconded to nonclinical settings were
excluded. While power analysis indicated that a sample of
 participants would provide sucient power (%) for
a statistically signicant (alpha = .) correlation in the
magnitude of . between the main study variables, consistent
with previous literature estimates []; the minimum sample
size was set to  in order to allow the exploration of the
metric properties of the measurement scales as well [].
3.4. Data Collection Procedure. Atotalofquestionnaire
packets along with consent forms were distributed to all
eligible members of the target population by personal visits
respond to the questionnaire at their own time and return
it in a sealed envelope by placing it in a box located at each
work setting for the purpose of the study. Aer  weeks, a
reminder was given and the boxes were collected by the end
questionnaires (response rate .%).
3.5. Instruments. e self-reported questionnaire pack con-
sisted of two parts: (i) demographic, educational, personal,
and work-related information and (ii) structured scales:
modied version of Moral Distress Scale for Mental Health
Services (M-MDS-MHS); Secondary Traumatic Stress Scale
(STSS); General Health Questionnaire- (GHQ-); and
Jeerson Empathy Scale (JES).
3.5.1. Part I
Sociodemographic and Personal Data. Two groups of sociode-
mographic data were collected: work history data (years
of nursing experience, years in the current position, type
of work setting, and rank) and personal variables (age,
Since international literature indicates association between
work-related dysfunctional attitudes and health-threatening
behaviours [, , ], the following variables were also
included in the personal data questionnaire: “How many
times in a week do you drink alcohol?” and “How many times
in a week do you exercise?” Additionally, since international
literature indicates association between work-related atti-
tudes and self-perceived social and personal life satisfaction
[, –], the following variables were also included in
the personal data questionnaire with a numeric rating scale
(NRS) response formulation: “Please, indicate from  to 
how satised you feel with your: (a) social life and (b)
personal life.” e range of the responses in these questions
was from : not at all satised to : completely satised.
In relation to work-related variables, the participants
also lled in a short questionnaire encompassing sta safety
measures, reecting MHNs’ workload. e information given
was about nurse-per-patient ratios and number of patients
treated in the setting. Nurses’ workload has been previously
associated with emotional exhaustion and mental and moral
distress [, , ]. Additionally, a question was included
regarding the intention to leave the current post, or having
quit a previous clinical post due to distress related to care or
patient-related decisions, since this factor has been associated
elsewhere with the main variables explored herein [, , ].
Job Satisfaction and Burnout Measures.Finally,aseriesof
questions regarding work-related attitudes were included
with a numeric rating scale (NRS): –. e rst item
regarded the (i) degree of emotional exhaustion, as the
core concept of professional burnout. is question was
formulated as follows: “Please, indicate from  to  how
emotionally exhausted do you feel due to your work,” while
the range of the responses in this question was from : not
at all exhausted to : completely exhausted. e second
question assessed the degree of satisfaction from (a) the
profession and (b) therapeutic relations. e formulation
and response range of the two latter questions was like the
emotional exhaustion question; that is, “Please, indicate from
 to  your level of professional satisfaction with regard to (a)
your work as MHN, (b) therapeutic relations with patients
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3.5.2. Part II
Moral Distress Assessment Instrument. e frequency and
intensity of morally distressing experiences were assessed
with a modied version of the Moral Distress Scale-Revised
(MDS-R), Adult Nurse Version, that is, M-MDS-MHS. e
M-MDS-MHS used in this study was largely based on the
Moral Distress Scale (MDS-R) by Hamric et al. [] aer
permission was obtained by the developers of the original
(Professor Corley) and the revised scale for nurses caring for
adults (Professor Hamric). e M-MDS-MHS used herein
was adapted accordingly for psychiatric clinical settings based
on the Moral Distress Scale developed by Ohnishi et al. []
and the MDS-R. Specically, since ve items (, , , , and
R scale, it was deemed necessary to integrate the remaining
ten items of the Ohnishi et al. [] scale to the MDS-R
version. Furthermore, item  of the MDS-R was eliminated
since it was not applicable to Mental Health Services context.
e modied scale was translated into Greek using the
the modied scale were assessed by a panel of ve experts. e
process resulted in a slight modication in the wording of a
number of items to correspond more eectively to the Mental
Health Services context, as well as the addition of two items.
e nal scale consisted of  items. e reasons and process
for developing the modied version of the scale is described
in detail elsewhere [].
Briey, the MDS-R scale developed by Hamric et al. []
was designed for acute settings, medical surgical, thus not
specic for mental health settings. As a result, organizational
or cultural conditions prevailing in mental health settings
may be underestimated by this tool. Similarly, although the
instrument developed by Ohnishi et al. [] was constructed
for Mental Health Services, it was however oriented for
hospital, mainly, institutional environments. Japanese Men-
tal Health Services have not followed deinstitutionalization
reformation. Consequently, the instrument has limited appli-
cability to healthcare systems of dierent orientation, that is,
in European or North American settings.
e M-MDS-MHS used herein encompasses two parts,
the frequency of morally distressing incidences is measured
on a -point Likert scale ranging from  (never) to  (very
frequently), with an overall score ranging from  to . In
the second part, participants rate the intensity of disturbance
felt when experiencing each distressing situation listed in
the rst part of the instrument on a -point Likert scale
ranging from  (none) to  (great extent). e overall score
on this part of the scale also ranges between  and .
Additionally, in order to measure the overall severity of moral
distress the score from each item in the rst part is multiplied
by the corresponding score in the second part, leading to
a composite score reecting both the frequency and the
intensity of the distressing experiences. For each item, the
score can range between  and . e theoretical range of
the “composite moral distress score” across all  items is 
to . e higher the score the higher the severity of the
experienced moral distress. Examples of the items included
in the M-MDS-MHS are as follows: “Work with levels of
nurse or other care provider stang that I consider unsafe”
or “Avoid taking action when I learn that a physician or nurse
colleague has made a medical error and does not report it”
or “I secretly mix medication into patients’ food or drink
M-MDS-MHS were assessed. Internal consistency reliability
assessed by Cronbachs alpha coecient was . for the
frequency MD scale and . for the intensity MD scale.
Construct validity was measured via factor analysis with
varimax rotation. e unidimensionality of the scale was
conrmed, explaining the .% of the variance for the
intensity subscale and . for the intensity subscale.
STSS Symptoms Assessment Instrument. e degree of symp-
toms of secondary traumatic stress syndrome was assessed
using the Secondary Traumatic Stress Scale developed by
Bride et al. []. is comprises  items constructed
according to the symptoms of posttraumatic stress disorder
described in the Diagnostic and Statistical Manual for Psy-
chiatric Disorders-IV-Text Revision []. Each item is rated
on a -point Likert scale, from  (never) to  (very oen).
In particular, respondents are asked to report the frequency
to which they have experienced the symptoms described in
each item during the previous two weeks. Examples of the
to concentrate.” e scores can range from  to , with
higher scores indicating more severe self-reported symptoms
of secondary traumatic stress syndrome. e items of the
scale address intrusion symptoms, avoidance symptoms, and
symptoms of arousal, reecting the three subscales of the
tool. Internal consistency reliability assessed by Cronbachs
alpha coecient has been reported previously as . for
the entire scale []. e validity of the scale has also been
assessed elsewhere [] via conrmatory factor analysis using
structural equation modeling, providing values representing
adequate model t; that is, GFI = ., CFI = ., IFI = .,
and RMSEA = .. Moreover, this procedure resulted in
the conrmation of the three factors included in the scale,
identied as intrusion, avoidance, and arousal []. Although
applicable in the unidimension version, as it was used herein
Empathy Assessment Instrument. e degree of empathy
among nurses was assessed by the Jeerson Scale of Empathy-
HP-Version []. is is a -item scale, rating nurses’ feelings
and perceptions of nurse-patient relationship on a -point
Likert scale. e responses to each item range from  (strongly
disagree) to  (strongly agree), and the total score can
range between  and . Internal consistency reliability
assessed by Cronbachs alpha coecient has been reported
previously as . []. Additionally, the construct validity
rotation. is procedure resulted in the conrmation of the
three factors included in the scale, identied as “Perspective
Taking”; “Compassionate Care”; and “Standing in Patients
Shoes” []. Although this scale may be applied as a three-
dimension tool, it is also applicable in the unidimension
BioMed Research International
version according to the constructors of the scale, as it was
used herein [, ]. Examples of the items included in
understand their feelings” or “I try to imagine myself in my
patients’ shoes when providing care to them.”
General Symptoms of Mental Distress Assessment Instru-
ment. e degree of general symptoms of mental distress
was assessed by the Greek version of the General Health
Questionnaire []. is is a widely used questionnaire
of  items, nonspecic measure of mental distress, oen
used as a screening tool for depressive and relevant anxiety
symptoms in both general population and clinical samples.
Likert scale [(): never to (): more than usual] divided
into  subscales, reecting the four dimensions of the tool:
general health disturbance symptoms (somatic symptoms)
( items); anxiety symptoms ( items); self-perception of
personal/social functioning ( items); and depressive symp-
toms and suicidal behaviour ( items) [, ]. e metric
properties of the GHQ- have been explored in numerous
studies [, ]. Values of Cronbach’s alpha ranging from
. to . regarding internal consistency reliability have
been reported for all the four subscales and the entire scale
elsewhere [, ]. Examples of the items are “Have you
recently felt ill/constantly under strain/that life is not worth
3.6. Data Analysis. Descriptive statistics of all sociodemo-
graphic and other variables were calculated using frequencies
or mean (𝑀) and standard deviations (SD) for categorical
and continuous variables, respectively. In the absence of
accepted cut-o values for all structured instruments applied
herein, we used the quartiles of the theoretical range of each
scale in order to interpret relevant scores as low, moderate,
or high. Additionally, since all instruments were used for
the rst time in Cypriot MHN, the study assessed their
metric properties. e dimensionality and construct validity
of the scales were assessed in exploratory factor analysis
with principal component extraction and varimax rotation
(reported elsewhere) []. e internal consistency of the
overall scale and subscales was estimated using Cronbachs
alpha coecient. Τest-retest reliability was assessed in a
subsample of  MHNs completing all scales twice, with one
week apart, using Kendal’s tau. is procedure was followed
to assess the stability of the instruments (temporal reliability).
Internal consistency and test-retest reliability values are pre-
sented in the Results. e overall and subscale scores for all
study variables were calculated as the sum of item responses,
according to the constructors of the instruments [, , ],
and normality checks were performed. Dierences in study
variables by sociodemographic and other characteristics of
the participants were assessed using parametric tests (𝑡-
test and one-way ANOVA) as appropriate. e correlation
between the main study variables was assessed by calculating
the Pearson correlation coecient. Finally, the association
between MD as indexed by the composite score (indepen-
dent) and STSS score (dependent variable) was assessed in
linear regression models before and aer adjusting for (a)
general symptoms of mental distress as measured by the
GHQ- (mediator) and for (b) other sociodemographic and
work-related characteristics (covariates). Data analysis was
performed in Statistical Package for Social Sciences ver. ..
4. Results
4.1. Sociodemographics, Work-Related Characteristics, Self-
Reported Satisfaction Measures, and Related Associations.
e nal sample consisted of  participants, mean age .
years [standard deviation (SD) = .], with . years of work
experience on average in Mental Health Services (SD = .), of
whom .% were men and .% were women. is is largely
consistent with the expected gender proportions among men-
tal health nurses in Cyprus based on ocial statistics (.%
and .%, for males and females, resp.). One in three held
a postgraduate degree (.%). e observed distribution in
the sample, in terms of the dierent geographical regions as
well as settings employed, was largely representative of the
expected proportions. Table  presents the sociodemographic
and work-related characteristics and attitudes of the partici-
pants, as well as their self-rated frequency of life-threatening
behaviours and degree of satisfaction with personal and
professional life. While participants rated satisfaction from
personal life (𝑀=.,SD=.)andsocialrelationships
(𝑀= ., SD-.) quite high on a NAS –, they rated
satisfaction from work quite low by comparison (𝑀=.,SD
.). On average, participants reported a moderate degree of
job-related emotional exhaustion (𝑀=.,SD=.),while
as many as one in four reported that they considered leaving
their current position. Based on the responses of –
participants who provided information with regard to sta
safety measures number of patients treated in the setting (𝑀
= ., SD = ., range –) and nurse-to-patient ratios (𝑀=
4.2. Summary Statistics for the Main Study Variables. Ta b l e 
presents descriptive statistics for the main study variables
along with Cronbachs alpha coecient for internal consis-
tency and test-rest correlation for the corresponding mea-
surements scales, which were satisfactory in all cases.
4.2.1. Frequency and Intensity of Morally Distressing Expe-
riences. e observed distributions of overall scores of the
frequency as well as the intensity of moral distress were fairly
symmetrical with 𝑀=.(median=.,SD=.,range:
–, and IQR: –) and 𝑀=.(median=.,SD
= ., range: –, and IQR: –), respectively. Using
the quartiles of the theoretical range of the scale (–)
in the absence of accepted cut-o values, the frequency
of morally distressful incidences would be characterized as
quartile: –). .% of the participants had scores in
the lower quartile of the theoretical range of the scale
(<), reporting never or rarely experiencing any of the 
potentially morally distressful situations. us, the remaining
participants (.%) reported that they experienced at least
BioMed Research International
T : Sociodemographic or work-related characteristics of the participants and self-reported satisfaction measures (𝑁 = 206).
Variabl e
Categories Frequency
(𝑁 = 206)Relative frequency (%)
Gender Female  .%
Male  .%
<  .%
–  .%
–  .%
  .%
Not reported .%
- or -year diploma .%
Bachelor degree  .%
Postgraduate degree  .%
Doctoral degree .%
Not reported .%
Marital status
Married/cohabiting  .%
Single  .%
Divorced, separated, widowed  .%
None  .%
One  .%
Two  .%
ree or more  .%
Physical activity
Never  .%
- times/week  .%
More than  times/week  .%
Not reported %
Alcohol use
Not weekly  .%
- glasses/week  .%
More than /week .%
Not reported .%
Nicosia  .%
Limassol  .%
Larnaca  .%
Paphos/Famagusta  .%
Athalassa psychiatric hospital  .%
Psychiatric wards in general hospitals  .%
Inpatient substance use treatment units  .%
Inpatient child/adolescent units  .%
Community mental health services  .%
Psychosocial rehabilitation units .%
Outpatient child/adolescent services  .%
Outpatient substance use treatment units  .%
Mental health services in Prison .%
Nurse  .%
Senior Nurse  .%
Nurse Manager .%
Intention to leave
Have previously le position .%
Considered leaving position  .%
Never considered leaving  .%
Not reported  .%
BioMed Research International
T  : C ontinu e d .
Variabl e
Mean (SD) Median (IQR)
Overall work experience (years) . (.) . (–)
Length of employment in current position (years) . (.) . (–t)
Job satisfaction (NAS –) . (.) . (–)
General personal life satisfaction (NAS –) . (.) . (–)
Satisfaction with social relationships (NAS –) . (.) . (–)
Satisfaction with therapeutic relations (NAS –) . (.) . (–.)
Degree of emotional exhaustion (NAS –) . (.) . (–)
T : Summary statistics (𝑁 = 206), Cronbachs alpha coecient of internal consistency (𝑁 = 206), and test-retest correlation coecient
for main study variables (overall scale and/or subscales).
overall scale
(number of items,
theoretical range)
Mean (SD) Median
(IQR) Range
Pearson’s 𝑟
Modied version of Moral
Distress Scale for Mental
Health Services
Frequency,  items
(theoretical range: –) 37.8 (20.1) 38 (24–51) 1–103 𝛼= . 𝑟 = 0.645
(𝑝 < 0.001)
Intensity,  items
(theoretical range: –) 76.4 (31.1) 71 (47–97) 0–127 𝛼= . 𝑟 = 0.793
(𝑝 < 0.001)
Composite score,
(theoretical range: –)
96.8 (62.9) 91 (51–135) 0–345
Secondary Traumatic Stress
 items
(theoretical range: –) 31.1 (10.2) 30 (24–37) 17–61 𝛼= . 𝑟 = 0.848
(𝑝 < 0.001)
Jeerson Scale of Empathy  items
(theoretical range: –) 105.9 (12.7) 106 (100–115) 69–134 𝛼= . 𝑟 = 0.897
(𝑝 = 0.006)
General Health
Somatic symptoms,  items
(theoretical range: –) 5.8 (3.5) 5 (3–8) 0–18 𝛼= . 𝑟 = 0.755
(𝑝 < 0.001)
Anxiety/insomnia,  items
(theoretical range: –) 5.4 (3.9) 5 (3–7) 0–18 𝛼= . 𝑟 = 0.751
(𝑝 < 0.001)
Social dysfunction,  items
(theoretical range: –) 6.7 (2.6) 7 (6-7) 0–17 𝛼= . 𝑟 = 0.680
(𝑝 = 0.001)
Depression,  items
(theoretical range: –) 5.0 (2.2) 1 (0–2) 0–12 𝛼= . 𝑟 = 0.845
(𝑝 < 0.001)
Overall,  items
(theoretical range: –) 19.4 (10.0) 17 (13–24) 0–55
some of the  situations described on the scale relatively
more frequently, and, in fact, as many as .% reported
experiencing at least one of these situations very oen.
Furthermore, the intensity of moral distress from these
incidences, irrespective of their frequency, is moderate to
high (i.e., in the third quartile –). As many as .%
of the participants had scores higher than  (top quartile
of theoretical range) on the moral distress intensity scale. In
terms of the various potentially morally distressful situations,
“assisting a doctor or/and a nurse, who according to my opinion
does not have the appropriate skills to provide care” was by
far the most frequently reported, with as many as .%
of the participants responding that this happens oen or
very oen (M = ., SD = .)—results not shown in detail.
is was followed by the statementïż£ “I undertake extensive
therapeutic interventions following medical instructions even
when I do not think they will change the clinical picture of the
patient,” reporting that they occur oen or very oen by %
of the participants (𝑀 = 1.9, SD = .). Nevertheless, these
were not the situations which were rated as the more intense
in terms of moral distress. In descending order, the top three
single items with the highest moral distress intensity scores
were as follows: “ignore situations where there is a suspicion
that one of the patients is being badly treated or abused by
someofthehealthcaresta,” with .% rating it as intense or
very intense, even though .% reported that it occurs oen
or very oen; “assist doctors in conducting examinations or
treatments without the informed consent of the patient,” with
.% intense/very intense and .% in terms of its frequency
(oen or very oen); and “the nurse-to-patient ratio is not
safe,” with % prevalence of intense/very intense and .%
in terms of its frequency (oen or very oen).
4.2.2. Degree of Secondary Traumatic Stress Syndrome Symp-
toms, Empathy, and General Mental Distress Symptoms. In
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terms of the other main study variables, the mean score
and standard deviations were as follows: 𝑀=.(SD=
.) on the STSS scale (indicating moderate to low degree
of symptoms of secondary traumatic stress syndrome on
average) and 𝑀= . (SD = .) on the Jeerson Scale
for Empathy (indicating moderate to high levels of empathy)
and 𝑀= . (.) on the GHQ- (indicating moderate
to high levels of general mental distress symptoms). As
many as .% of the participants had scores higher than
of the scale, indicating clinically relevant symptoms, with
higher scores on average in descending order, in terms of
personal/social dysfunction, somatic symptoms, anxiety, and
depressive symptoms subscales.
4.3. Associations between MD Measures and Main Study
Variab l e s . Table  presents the correlations between the main
study variables. A moderate positive correlation was observed
between the composite score of MD (frequency ×intensity)
and STSS scale score (𝑟 = 0.35;𝑝value <.). Composite
moral distress score also showed a moderate positive cor-
relation to general mental distress symptoms, as measured
by the GHQ- (𝑟 = 0.29;𝑝value <.), with higher
correlations with somatic symptoms and anxiety/insomnia
subscales. Furthermore, the GHQ- score had a strong
positive correlation (𝑟 = 0.65;𝑝 < 0.001)withthe
STSS score, with the strongest correlation observed with the
anxiety/insomnia subscale (𝑟 = 0.70;𝑝 < 0.001), followed by
somatic symptoms (𝑟 = 0.52;𝑝 < 0.001), and the weakest
correlation with self-perceived personal/social dysfunction
subscale (𝑟 = 0.37;𝑝 < 0.001). Finally, in terms of empathy as
measured by Jeerson Scale of Empathy, with the exception
of a small positive correlation with the intensity of moral
distress (𝑟 = 0.18) and a negative correlation with depressive
symptoms (𝑟 = −0.21), no other signicant correlations
were observed between empathy scores and the main study
ere were mild statistically signicant correlations
between composite moral distress score and (a) satisfaction
from therapeutic relations (𝑟 = −0.21;𝑝 < 0.010), (b)
degree of emotional exhaustion (𝑟 = 0.19;𝑝 = 0.01), and
(c) job satisfaction (𝑟 = −0.15;𝑝 = 0.03), but there was no
association with general life satisfaction and satisfaction from
social relations—see Table . In descending order, degree
of job satisfaction was strongly and statistically signicantly
correlated with the degree of satisfaction from therapeutic
relations (𝑟 = 0.535), emotional exhaustion (𝑟 = −0.400),
and general life satisfaction (𝑟 = 0.256)—results not shown
in detail.
4.4. Dierences in the Frequency, Intensity, and Composite
Moral Distress Scores by Sociodemographic and Work-Related
Characteristics. Table  shows the observed dierences in
levels of moral distress score according to sociodemographic
dierences were assessed using the parametric 𝑡-test (com-
parisons between two independent groups of the samples)
and one-way ANOVA test (comparisons among more than
two independent groups of the sample) as appropriate.
Table  also depicts correlations between all three moral
distress scores (composite, intensity, frequency scores) and
satisfaction variables, assessed with Pearson’s 𝑟coecient.
ere was a negative correlation between moral distress score
and length of employment in the current position, which
indicates that younger MHN with fewer years of experience
are more likely to report higher levels of moral distress. Con-
sistently, lower levels of moral distress were observed in terms
of the age of the participants and their rank, with the lowest
scores observed among participants over  years of age (𝑀=
62.7 versus around  in all other age-groups; 𝑝 < 0.001)
and among senior nurses/managers (𝑀 = 52.3versus . in
nurses; 𝑝 < 0.001). No other statistical signicant dierences
were observed in moral distress scores by sociodemographic
and work-related characteristics, including no dierences
in terms of the reported intention to quit, or sta safety
4.5. Association of Moral Distress with Secondary Traumatic
Stress Syndrome Symptoms and the Mediating Eect of Mental
Distress Symptoms. Table  presents the association between
composite moral distress score and STSS scale score as esti-
(a) for job satisfaction, satisfaction from therapeutic relations
and emotional exhaustion (all important covariates), as well
by the GHQ-, which was found to be highly correlated
with both the self-reported level of moral distress and the
STSS scale score and composite moral distress score, aer
controlling for job satisfaction, satisfaction from therapeutic
relations, and emotional exhaustion with a standardized beta
coecient of . SD increase in STSS scale score per
SD increase in the moral distress composite score. Aer
further adjusting for GHQ- score, the observed association
attenuates slightly (st. beta = .), suggesting that the
association between moral distress and secondary traumatic
stress syndrome symptoms is partly mediated by general
symptoms of mental distress but remains statistically signif-
icant. No other study variables showed an association with
STSS scale score. Specically, the degree of empathy showed
no association with the severity of STSS symptoms (Table )
and there was no attenuation in the observed association aer
beta = .; 𝑝value = .)—not shown in detail. e
association also remained largely unchanged aer adjusting
for gender, age, number of children, education, rank, and
intention to quit (standardized beta = .; 𝑝value =
.). In fact, in a stepwise regression model with backward
elimination including all study covariates, only moral distress
composite score, GHQ- score, and emotional exhaustion
score were predictive of STSS scale score, explaining .%
of the variance—results not shown in detail. Furthermore,
while the association between moral distress composite score
compared to male MHN (standardized beta = . versus
.), there was no evidence for eect modication (𝑝for
 BioMed Research International
T : Pearsons correlation coecients (𝑝values) between main study variables (𝑁 = 206).
intensity SPTS Scale Jeerson Scale
of Empathy
GHQ, anxi-
M-MDS-MHS, Composite .
M-MDS-MHS, Frequency .∗∗∗ .
M-MDS-MHS, Intensity .∗∗∗ .∗∗∗ .
STSS Scale .∗∗∗ .∗∗∗ .∗∗ .
Jeerson Scale of Empathy . . .∗∗ . .
GHQ-, overall .∗∗∗ .∗∗∗ .∗∗ .∗∗∗ . .
GHQ, somatic symptoms .∗∗∗ .∗∗∗ .∗∗ .∗∗∗ . .∗∗∗ .
GHQ, anxiety/insomnia
symptoms .∗∗∗ .∗∗∗ .∗∗ .∗∗∗ . .∗∗∗ .∗∗∗ .
GHQ, personal/social
dysfunction . . . .∗∗∗ . .∗∗∗ .∗∗∗ .∗∗∗ .
GHQ, depressive symptoms ... .∗∗∗ .∗∗ .∗∗∗ .∗∗∗ .∗∗∗ .∗∗∗ .
value <., ∗∗value <., and ∗∗∗value <..
BioMed Research International 
T : Dierences in the frequency, intensity, and composite moral distress score by sociodemographic and work-related characteristics.
Variable Categories
Moral distress,
Mean (SD)
Moral distress,
Mean (SD)
Moral distress,
composite score
Mean (SD)
Female . (.) . . (.)
Male . (.) . . (.)
𝑝value. . .
< . (.) . (.) . (.)
– . (.) . (.) . (.)
– . (.) . (.) . (.)
 . (.) . (.) . (.)
𝑝value<. . .
Diploma/Bachelor degree . (.) . (.) . (.)
Postgraduate/Doctoral . (.) . (.) . (.)
𝑝value. . .
Marital status
Married/cohabiting . (.) . (.) . (.)
Single . (.) . (.) . (.)
Divorced, separated, widowed . (.) . (.) . (.)
𝑝value. . .
None . (.) . (.) . (.)
One . (.) . (.) . (.)
Two . (.) . (.) . (.)
ree or more . (.) . (.) . (.)
𝑝value. . .
Physical activity
Never . (.) . (.) . (.)
- times/week . (.) . (.) . (.)
More than  times/week . (.) . (.) . (.)
𝑝value. . .
Alcohol use
Not weekly . (.) . (.) . (.)
- glasses/week . (.) . (.) . (.)
More than /week  (.) . (.) . (.)
𝑝value. . .
Nurse . (.) . (.) . (.)
Senior nurse/manager . (.) . (.) . (.)
𝑝value<. <. <.
Intention to
Have le/considered leaving . (.) . (.) . (.)
Never considered leaving . (.) . (.) . (.)
𝑝value. . .
Variable Pearsons correlation coecient (𝑝value)
Overall work experience (years) . (.) . (.) . (.)
Length of employment in current position
(years) . (.) . (.) . (.)
Job satisfaction (NAS –) . (.) . (.) . (.)
General personal life satisfaction (NAS –) . (.) . (.) . (.)
Satisfaction from social relationships (NAS
–) . (.) . (.) . (.)
Satisfaction from therapeutic relations (NAS
–) . (<.) . (<.) . (<.)
Degree of emotional exhaustion (NAS –) . (.) . (.) . (<.)
value of independent -test or one-way ANOVA as appropriate.
 BioMed Research International
T : Association of secondary traumatic syndrome symptoms with moral distress before (model ) and aer adjusting for work-related satisfaction covariates (model ) and mental
distress level (model ).
Secondary Traumatic Stress Scale score
Univ ariable model
(model )
Aer adjusting for satisfaction and
emotional exhaustion covariates (model ) Also, adjusting for GHQ- score (model )
BSt. error St. beta 𝑝value bSt. error St. beta 𝑝value bSt. error St. beta 𝑝value
Moral distress
composite score . . 0.345 <. . . 0.269 <. . . 0.154 .
Job satisfaction level . . . , . . . .
Satisfaction from
therapeutic relations . . . . . . . .
Emotional exhaustion
level . . . <. . . . .
GHQ- score . . . <.
𝐹 = 27.896,𝑝 < 0.001,adjusted𝑅2= 0.12 𝐹 = 13.833,𝑝 < 0.001,adjusted𝑅2= 0.20 𝐹 = 34.422,𝑝 < 0.001,adjusted𝑅2= 0.45
BioMed Research International 
interaction = .). Finally, there was no eect modication
on the association between moral distress composite score
and STSS score by age-group, education, rank, or intention
to quit.
5. Discussion
For the rst time, in a sample of mental health nurses in
Europe, we assessed the intensity and severity of morally dis-
tressing situations, along with associations with the severity
of secondary traumatic stress syndrome symptoms, and the
mediating eect of general symptoms of mental distress. In
contrast to previous investigations, we used an instrument
addressing mental health practice both in the community and
in mental health institutions, and we used a census sampling
method to invite participation of all MHNs in Cyprus. We
observed a positive association between the overall severity of
moral distress and the manifestation of secondary traumatic
stress syndrome symptoms, partially mediated by the degree
of self-reported mental distress symptoms. Additionally, for
the rst time, we adjusted for a number of sociodemographic
new perspective to the so far limited data on the association
between the severity of moral distress and secondary trau-
matic stress syndrome within the context of Mental Health
Services [, ].
Yet, the contribution of the present data may be viewed
under the light of lack of quantitative data regarding the
intensity and severity of moral distress especially in mental
health nurses in a European setting. Previous studies in this
group of nurses either involved non-European populations,
specically Jordanian [] and Japanese nurses, [] and
qualitative approaches [, , ], or have assessed concepts
related to moral distress, for example, moral sensitivity, ethi-
cal climate, or ethical stress, as the severity of general stress
responses related to moral dilemmas []. An additional
contribution of this study is the use of an instrument specic
nurses. In contrast, Ohnishi et al. [] and Hamaideh []
have used an instrument culturally oriented for hospital,
mainly institutional, environments.
Frequency and Intensity of MD. e associations presented
herein may be of particular signicance for quality and
safety improvement initiatives, since international literature
signposts that health professionals’ mental health status and
work-related stress are of increasing concern due to their
impact on sta and patient quality and safety standards [,
–]. Data show that the vast majority of situations related
to morally distressing experiences concern patient safety
issues []. As a result, the frequency and intensity of morally
distressing experiences among clinicians may be indicators of
healthcare setting []. Indeed, the top items with the highest
morally distressing intensity and frequency reported herein
regarded working with incompetent colleagues, application
of unnecessary, extensive, and without consent therapeutic
interventions, suspicions of patient abuse, and working under
unsafe nurse-to-patient ratios. us, interventions oriented
to both organizational culture and policies, with special
focus on the particular conditions and needs prevailing in
mental healthcare sector, are proposed. e importance of
this approach is twofold. Firstly, morally distressing situations
may be addressed and further managed having a direct,
positive impact on patient safety standards. On the other
hand, such interventions are important in mitigating work-
related risks, mainly moral distress and related secondary
traumatic stress syndrome symptoms, which may render
nurses’ vulnerable to severe mental and physiological health
problems, with subsequent eects on patients’ safety [, ].
In more detail, since moral distress has been associ-
ated with both mental distress and secondary traumatic
stress symptoms herein, this may denote that fundamental
neurocognitive functioning, such as cognitive procedures
and perception, as well as emotionality, may be disrupted
under morally distressing conditions []. Relevant mental
disturbances, if not treated eectively, may inuence MHNs
professional performance within the work environment,
including professional and therapeutic relations, along with
communication issues, errors during medication treatment,
patients’ surveillance, and continuity of care [, , ]. e
or turnover associated with diminished level of health [, –
Factors Associated with MD. In relation to the factors linked
with moral distress, although we have found that younger
MHN with fewer years of work experience are more likely
to experience higher levels of moral distress, and that one
out of four participants reported intention to quit the job
due to moral distress, there was no eect modication on the
association between moral distress and secondary traumatic
stress syndrome symptoms by age-group, rank, or intention
to quit. is lack of modication eect may signify that the
eects of moral distress are uniform across groups of MHN
and that neither age nor longer work experience and no
rank can protect nurses, who experience both mental and
moral distress symptoms, from developing traumatic symp-
tomatology. Furthermore, the association between moral
distress and severity of secondary traumatic stress syndrome
symptoms remained largely unchanged aer adjusting for
gender, number of children, and education, which may
further denote the universal impact and profound eects of
moral distress, regardless of the dierences in one’s context
and presumably coping style.
erefore, resilience to moral distress may not be easily
attainable based on personal attributes or circumstances
[]. Indeed, a recent consensus committee on developing
resilience to moral distress focused on policy, practice, and
education []. ough experienced on a personal level,
moral distress needs to be viewed as an organizational prob-
lem. us, eective interventions need to address the sources
of moral distress within the social and organizational context
of the workplace. Although resilience among clinicians may
be an important buering personality trait, it cannot be an
eective antidote to moral distress, especially when the work
environment is permissive to circumstances leading to moral
 BioMed Research International
Overall, organizational empowerment oriented interven-
tions are proposed to allow MHNs to speak up and advocate
eectively for the patients they care for, mainly within the
multiprofessional therapeutic teams []. Special focus needs
to be paid in younger and novice nurses, that is, younger
than  years old, sta MHNs. It seems that probably due to
the subculture of the organization or the setting of employ-
ment this group of nurses is more frequently reluctant to
reveal information regarding morally distressing situations.
is may be explained through the adaptation model of
as adaptive, unique structures of interrelated systems, that is,
biological, psychological, and social, which have inputs and
outputs, along with an internal process aiming to maintain
a balance between the three interrelated systems (biological,
psychological, and social) and the outside environment, that
is, the working environment of Mental Health Services.
of balance, while MHNs strive to adapt within a unique
band in which they can cope adequately. erefore, MHNs,
in order to sustain the balance between their needs linked
with the social system (acceptance from colleagues) and the
work environment, may not reveal disturbing information
or impeaching data for a healthcare organization regarding
patient safety standards. On the other hand, although an
adaptation process may be ongoing, it is possible an for
an imbalance, between the system of MHNs’ psychological
needs and the ethical climate of the work environment, to
occur, which may be reected on disturbed mental health
among MHNs, for example, anxiety and depressive symp-
the formation of targeted interventions aiming to decline
both formal and informal organizational structures which
encumber MHNs to advocate eectively for the patients, or
even their colleagues. Relevant interventions may include
augmentation of the degree of nurse managers’ participation
in committees related to both mental healthcare policy
making and administration of Mental Health Services, there-
fore to support issues and decisions which enhance MHNs’
structural empowerment, that is, access for all ranking sta
nurses to resources and information. Furthermore, MHN
managers need to support novice sta MHNs to speak up
and suciently participate in clinical decision-making about
direct patient care. Nevertheless, the acknowledgement of
the input of novice sta nurses by nurse managers, both
in private and within the interdisciplinary therapeutic team,
may empower novice nurses to speak up and provide valuable
information in relation to morally distressing issues linked
with patient safety.
Additionally, nurses, and especially younger and less
experienced nurses, need to be empowered organization-
ally in terms of eective collaboration with physicians and
colleagues, as well as enhanced clinical and organizational
autonomy []. Unit-based interventional programs aiming
to enhance the quality of communication among colleagues,
as well as with the members of multidisciplinary team [],
along with establishment of multidisciplinary rounds []
may be useful towards this goal.
Nevertheless, MHNs need to be also personally empow-
ered. is may be achieved through interventions which pro-
mote implementation of eective coping strategies towards
work-related stress and assertiveness attitude, as well as in-
unit education in the issues of moral distress. Assertiveness
training is expected to enable MHNs to overcome the existing
informal hierarchy within colleagues and interdisciplinary
team in cases they perceive that their moral code is violated
either by the rules and norms of the healthcare organization
or by the decisions of other healthcare employees [].
Education aiming to empower and enhance a critical clinical
approach, along with engagement in continuing professional
development, is also expected to increase the accountability
of novice and low-ranking sta nurses, as well as to promote a
productive collaboration with the rest of the members of the
multidisciplinary team.
Degree of Emotional Exhaustion, Job Satisfaction, and Empa-
thy. e participants herein reported a moderate degree
of work satisfaction, empathy, and job-related emotional
exhaustion. e latter was also a predictive of secondary
traumatic stress syndrome symptoms. e severity of the
emotional exhaustion level, along with the moderate levels of
job satisfaction, may be explained on the basis of the recent
reformation of Mental Health Services in Cyprus. During
the last three decades, there has been a gradual move of
therapeutic services from institutional (Athalassa hospital)
to community settings. To date, community Mental Health
Services are available to individuals and their families that
experience distressing situations or chronic and acute mental
health problems, across Cyprus []. Nevertheless, although
the vast majority of Mental Health Service consumers visit
community settings, the majority of MHNs are employed
in institutional (Athalassa hospital) and hospital settings
(psychiatric clinics in general hospitals). International data
suggests that the reformation of Mental Health Services is
followed by greater demands on community MHNs and can
subsequently result in increased workload in conjunction
with the greater complexity of the needs of the community
Mental Health Service consumers []. us, the increased
demands of the reformed professional role may have taken
their toll on Cypriot MHN’s work-related stress and feelings
about their job []. Policy makers need to address these
issues and intervene accordingly. For instance, postgraduate
care organization of MHNs’ employment may empower
MHNs to eectively manage the complex needs of Mental
Health Service consumers. e aforementioned context may
have also inuenced the degree of empathy reported herein.
Association among MD, STSS, Mental Distress, and Emotional
Exhaustion. e association among emotional exhaustion,
moral distress, STSS, and mental distress may suggest that
the recent reformation in the Mental Health Services and
high levels of emotional exhaustion—along with the current
organizational, typical and atypical, norms existing may have
BioMed Research International 
bent MHNs more vulnerable to the development of both
STSS and moral distress symptoms []. Data show that
exposure to prolonged stress is associated with decrease in
the Brain Neurotrophic Factors [, , ]. is condition
has been also associated with susceptibility to anxiety and
depressive symptoms, as well as relevant manifestations,
probably suggesting vulnerability to moral distress or STSS
regarding longitudinal studies on the association between
work-related stress, biomarkers, and moral distress or STSS
symptoms may be valuable. However, we need to state that
this association denotes the opposite as well, that is, that those
MHNs who experience symptoms of STSS or moral distress
are more prone to develop professional burnout symptoms.
Additionally, the mediating eect of emotional exhaus-
tion on the association between moral distress and STSS
symptoms may be also explained on the basis of the informa-
tion exchanged within the context of the therapeutic relation
with patients [, ]. In more detail, many times the ther-
apeutic communication encompasses patients’ confessions
about traumatic experiences, for example, being a victim or
an oender of sexual or physical abuse []. As a result,
MHNs may be inuenced by this confession in terms of
symptoms of secondary traumatic stress symptoms. At the
same time, if they are not able to reveal relevant information
or to advocate for the victims, for example, to activate legal
procedures towards those involved in such circumstances,
it is possible to experience symptoms of moral distress [].
Moreover, the eective therapeutic management of these
patients, as well as legal consequences of the perpetrators,
may be also hindered due to inadequate law system or referral
systems within Mental Health Services, lack of qualied
mental health professionals, for example, forensic personnel,
or even heavy workload and insucient time for communi-
cation with patients [–, ]. Such conditions may trigger
not only morally distressing symptoms for the vulnerable
personnel but emotional exhaustion, as well.
e Mediating Eect of Mental Distress Level on the Asso-
ciation between MD and STSS. e association between
moral distress and symptom severity of secondary traumatic
stress syndrome, partially mediated by the manifestation of
symptoms of mental distress, may suggest that mental health
nurses experiencing clinically relevant symptoms of mental
distress are more prone to develop secondary traumatic stress
symptoms related to morally distressing situations in their
daily clinical practice. is nding denotes that the cost of
unresolved moral distress may be high in nurses addition-
ally experiencing mental distress symptoms. One possible
explanation may be that those nurses who experience general
symptoms of mental distress, mainly depressive ones, most
of the times have decreased self-esteem. us, encountering
morally distressing situations may further compromise ones
personal integrity and self-esteem making him/her more
vulnerable to further worsening of depressive and anxiety
symptoms. In that case nurses may perceive that they aban-
don their moral principles due to fear, expediency, or self-
protection, resulting in further decrease of their self-esteem
and further worsening of preexistent anxiety or depressive
symptoms [, ].
e aforementioned ndings highlight the necessity for
the development and implementation of supportive inter-
ventions for vulnerable groups of MHNs, such as those at
higher risk to encounter morally distressing situations (e.g.,
employed in involuntary admission wards) []. Moreover,
nurses already reporting mental distress symptoms need to
situations in order to prevent deterioration. Counseling,
along with supportive and educative clinical super vision, may
be useful for this group [, ]. In Cyprus, there is a lack
of that kind of professionals’ support in place for MHNs,
who may only seek such services privately. Nevertheless, the
cost of counseling is high, thus not aordable to the vast
majority of clinical MHNs. is lack of supportive systems
in the Cypriot healthcare system needs to be addressed;
therefore interventions implemented by healthcare managers
and policy makers towards this goal are proposed. e
aim is to incorporate within each organization ocially
provided supportive counseling services for mental health
Although moral distress may be a phenomenon attributed
to workplace rather than to personal characteristics, raising
awareness of moral distress and its eects may empower
nurses and instigate organizational change. us, along with
interventions regarding changes in the organizational culture
and institutional framework of clinical MHNs, it would be
advisable to enrich the curricula of nursing and other health
professionals educational programmes with work-related
stress topics, including burnout, moral distress, and vicarious
trauma giving special emphasis to preventive strategies along
against these phenomena.
According to Austin et al. [] “although the term, moral
distress, is not part of our ordinary language, using it can
help us speak to the moral domain of our practice.” When
individuals are informed about a topic, they are also able to
name relevant experiences, which may lead them to a higher
level of awareness []. When p erceptions and feelings are put
into words people are empowered to act upon them. Naming
and understanding the distress that arises when nurses are
blocked from responding to the needs of their patients are
the rst step towards empowering themselves to action [].
Overall, the debate about ethics in clinical settings can be
productive and positive, a sign that healthcare providers are
engaged in collaborative relationships and concerned about
the quality of care for their patients [].
Furthermore, nursing managers need to be aware of these
phenomena. Nevertheless, experiences of moral distress are
further compounded when clinicians perceive managers and
administrators as not being adequately open or supportive
during morally challenging situations [].
Our results may also suggest that optimal mental health
status in MHNs functions as a buer system against the
impact of morally distressing or trauma situations experi-
enced within the work context. Based on this, interventions
supporting mental health in MHNs may decrease their
 BioMed Research International
susceptibility to the negative impact of prolonged work-
related stress. Recently, holistic interventions, such as S&R
(a program providing healthy snacks and holistic relaxation
modalities), have been implemented for healthcare employ-
ees, aiming to alleviate immediate feelings of work-related
stress []. ese interventions have been associated with
decrease in self-reported stress, respiration, and heart rate.
In conclusion, consistent provision of occupational health
services within workplaces needs to be incorporated as a vital
component of the public health strategy.
5.1. Limitations. e present ndings need to be regarded
in the context of specic methodological limitations. e
cross-sectional design of the study does not permit causal
inferences with regard to the direction of the relation-
ship between professional moral distress and symptoms
of secondary traumatic stress syndrome []. While the
observed association is strong, reverse causality cannot be
ruled out. MHN with secondary traumatic stress syndrome
symptomatology may be more likely to experience or at
least report more intense moral distress. Similarly, while the
study showed that the association between moral distress
and secondary traumatic stress syndrome symptoms was
mediated by symptoms of mental distress, it is also likely
that mental distress (which could be the result of a number
of non-work-related situations) is also a cofounder in this
association; that is, MHN with mental distress symptoms may
be more likely to experience moral distress as a result. While
also likely that other life stressors beyond work tension are at
play. Nevertheless, the association between moral distress and
secondary traumatic stress syndrome symptoms remained
unchanged aer controlling for satisfaction with social and
general personal life, which was reported to be quite high
in contrast to work satisfaction and work-related emotional
exhaustion. Another issue related to the limitations of the
present study is the use of the M-MDS-MHS instrument for
the assessment of moral distress, developed for the purpose
of the present study []. Although its development was
adequate metric properties, its content and construct validity
need to be further explored. A particular strength of the study
is the inclusion of nurses from diverse work settings, as well
as the fact that the entire nursing population employed in
Mental Health Services was approached. Furthermore, the
composition of the sample is representative of the expected
distribution of the workforce employed in Cypriot Mental
Health Services, according to ocial data. us, the nd-
ings may be generalized to the nursing populations of all
mental healthcare settings. Nevertheless, the extent to which
selection bias may have inuenced the observed association,
due to the voluntary nature of participation and the lower
response rate, is not known. It is possible that nurses suering
from severe mental and/or moral distress symptoms were less
likely to participate. us, we may have underestimated the
actual frequency and severity of relevant symptoms, which
nevertheless appear quite high.
Future Perspectives for Research. Future prospective studies
need to investigate work-related factors that may lead to both
moral distress and symptoms of mental distress, including
secondary traumatic stress syndrome. Also, both qualitative
and quantitative studies, exploring moral distress experi-
ences, taking into account gender inequalities and power
relations within the healthcare systems, or even adaptation
future researchers aiming to develop instruments for the
measurement of moral distress in healthcare professionals,
mainly employed in Mental Health Services, need to include
issues relevant to secondary traumatic stress factors, as well
as to increase the inclusion of factors related to workload and
emotional exhaustion factors.
6. Conclusions
Our ndings provide preliminary evidence of the association
between moral distress and secondary traumatic stress symp-
toms in MHN. Since secondary traumatic stress syndrome
symptoms were more likely among mental health nurses
who experienced morally distressing situations, and general
symptoms of mental distress, supportive interventions are
warranted. Situations that may lead health professionals to
be in moral distress seem to be mainly related to the work
environment; thus interventions related to organizational
empowerment of MHNs need to be developed.
Conflicts of Interest
e authors declare that they have no conicts of interest.
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... First, it affects healthcare professionals' wellbeing in various ways. According to various studies, moral distress correlates with worsened physical and mental health (AACCN 2020;Fard et al. 2020;Christodoulou-Fella 2017). Symptoms often associated with it can be emotional such as frustration, anger, and guilt; physical, such as muscle aches, headaches, heart palpitations, neck pain, diarrhea, or vomiting; and mental problems such as depression, PTSD, risk of suicide emotional detachment, and the inability to build healthy relationships and empathy. ...
... Symptoms often associated with it can be emotional such as frustration, anger, and guilt; physical, such as muscle aches, headaches, heart palpitations, neck pain, diarrhea, or vomiting; and mental problems such as depression, PTSD, risk of suicide emotional detachment, and the inability to build healthy relationships and empathy. Empirical studies have also shown that those who score higher in reports of moral distress are more likely to score highly on validated instruments to detect and diagnose psychiatric morbidity (Christodoulou-Fella et al. 2017). Second, moral distress has consequences for workplace functioning and thus ultimately for the wellbeing of patients. ...
... 2 We thank an anonymous reviewer for inciting us to clarify this point. -Fella et al. 2017;Lake et al. 2022;Firouzkouhi et al. 2021). Concern about the subjective psychosocial ramifications that moral distress has on those who experience it, regardless of what the sources of that distress are, is thus important in itself (Prentice et al. 2020;Carse and Rushton 2017). ...
While various definitions of moral distress have been proposed, some agreement exists that it results from illegitimate constraints in clinical practice affecting healthcare professionals' moral agency. If we are to reduce moral distress, instruments measuring it should provide relevant information about such illegitimate constraints. Unfortunately, existing instruments fail to do so. We discuss here several shortcomings of major instruments in use: their inability to determine whether reports of moral distress involve an accurate assessment of the requisite clinical and logistical facts in play, whether the distress in question is aptly characterized as moral, and whether the moral distress reported is an appropriate target of elimination. Such failures seriously limit the ability of empirical work on moral distress to foster appropriate change.
... Moral distress is best defined as "the experience of frustration and failure that arises from a professionals' struggle to fulfill their moral obligations to patients, families, and the public" [5]. Although moral distress is considered important to improve quality performance among general health practitioners, it is assumed to be more significant to mental health professionals [6,7]. Therefore, moral distress would influence the quality of care provided by MHPs and their relationships with patients. ...
... Moral distress is gaining significant attention in the psychiatric literature [8]. Several studies reported that moral distress is prevalent among psychiatric professionals [6,9,10]. In order to understand the relationship between moral distress and mental health practices, one must recognize that mental health practitioners use therapeutic-self as the primary tool. ...
Background It is assumed that understanding moral distress and its correlated factors among mental health professionals would enhance understanding of the ethical dilemmas that mental health professionals are confronting. Objectives To identify moral distress determinants among Jordanian mental health professionals working in psychiatric in-patient settings. Methods A cross-sectional descriptive design was used, employing self-administered questionnaire. Results Two- steps multiple hierarchical regression analysis showed that model 1 that includes the demographic characteristics, was significant with R ² = .151, while in model 2 that included demographics and the psychological characteristics of stress factors, it was found to be also significant R ² = .243. Conclusion Morally distressing environments might diminish the quality of psychiatric care provided as well as the job satisfaction among healthcare providers.
... Pre-COVID-19, research into nurses' wellbeing has highlighted the intense pressure experienced by the nursing and midwifery workforce across the globe (Christodoulou-Fella et al., 2017). When compared to the rest of the UK workforce, nurses are at greater risk of work-related stress, burnout and mental health problems such as depression and anxiety (Kinman et al.'s, 2020). ...
... When compared to the rest of the UK workforce, nurses are at greater risk of work-related stress, burnout and mental health problems such as depression and anxiety (Kinman et al.'s, 2020). The experience of many nurses in the UK and internationally has been viewed as creating a toxic cocktail of unmanageable demands and limited autonomy (Christodoulou-Fella et al., 2017;Kinman et al., 2020;World Health Organization [WHO], 2006. The unprecedented working conditions experienced by nurses during the COVID-19 pandemic have further exacerbated this . ...